Bypass Marketing: Are Docs Influenced?

Although they are prescription drugs, Viagra, Prozac, Allegra and many others are pitched directly to consumers. Do physicians take notice? HBS professor Alvin Silk and Harvard's Joel Weissman discuss a recent study.

by Manda Salls

Until the close of the last decade, health consumers received much of their knowledge and advice about prescription drugs from their physicians or other health care professionals. Today, pharmaceutical companies are spending several billion dollars a year to advertise directly to these consumers. For example, ads for Viagara, Prozac, and Allegra are seemingly everywhere, and have helped create powerful brands.

Of course, this practice gives rise to much controversy. Does direct-to-consumer advertising (DTCA) make health consumers more informed, or just persuaded? Do physicians prescribe one brand over another based on their patients' requests?

What follows is an HBS Working Knowledge interview with two authors of the study, Alvin Silk, Harvard Business School Professor Emeritus, and Joel Weissman, associate professor, department of Medicine and Health Care Policy, Harvard Medical School.

The Physicians Report ran in the April issue of the journal Health Affairs, and was co-authored by Silk; Weissman; David Blumenthal, professor at Harvard Medical School and a member of the Institute for Health Policy at Massachusetts General Hospital; Michael Newman, a senior research manager at Harris Interactive; Kinga Zapert, vice president for health policy research at Harris Interactive; Robert Leitman, division president, Health Care, Harris Interactive; and Sandra Feibelmann, a member of the Institute for Health Policy.

Manda Salls: When did the pharmaceutical industry begin direct-to-consumer advertising?

Alvin Silk: DTCA has a long history but a short past. The advertising of prescription drugs directly to consumers as we have come to know it was first advocated by the pharmaceutical industry in 1981. In 1983, the FDA requested a voluntary moratorium on such advertising in order to study its likely effects. The FDA lifted that moratorium in 1985 and established its authority to regulate DTCA.

The question of whether advertising 'informs' or 'persuades' consumers is the subject of a long and ongoing stream of debate and research.— Alvin Silk

Initially there was relatively little use for DTCA but it grew rapidly in the 1990s. In August 1997, the FDA issued guidelines for DTCA of drugs in broadcast media. The FDA guidelines served to reduce the uncertainty regarding permissible DTCA content and so 1997 is viewed as the watershed point in the use of DTCA. Since then, DTCA has increased dramatically. Outlays for DTCA doubled between 1997 and 2001 when they reached $2.7 billion.

Total promotional spending (including that directed toward physicians) as a percentage of pharmaceutical sales remains relatively constant over time and thus the growth of DTCA represents a shift in the mix of promotional spending by pharmaceutical firms. DTCA accounts for about 15 percent of expenditures for drug promotion of all kinds and the bulk of that spending continues to be directed toward health care professionals.

Q: What was the purpose of your study and what methods were employed?

Joel Weissman: Our study was concerned with how physicians see DTCA affecting their practices and the health of their patients. We focused on the following questions:

How often and for what sorts of conditions do physicians prescribe advertised drugs requested by their patients?

What other health care recommendations do physicians make as a result of visits with patients that involve discussions of advertised drugs?

How frequently do physicians prescribe advertised drugs when other drugs or treatments may be equally effective?

We surveyed a national probability sample of 643 physicians practicing in a wide variety of specialties. Data were collected primarily by means of a mail questionnaire. Approximately 5 percent of the sample chose to respond online. The overall response rate was 53 percent.

Q: What was the overall reaction to DTCA from physicians in your sample?

Weissman: Quite mixed! Overall, 40 percent felt that DTCA had a positive effect on their patients and their practices, while 30 percent viewed the effect as negative. The remaining 30 percent felt that it had no effect. More than two-thirds indicated that DTCA helped educate patients about available treatments, and about the same proportion reported it helped them to have better discussions with their patients.

However, four out of five doctors believed that DTCA did not provide information in a balanced manner, and a similar proportion felt that it encouraged patients to seek treatments they did not need. Physicians as a group were more equivocal about other impacts of DTCA, with 46 percent agreeing that it increased patients' compliance, and 32 percent agreeing that it made patients less confident in their doctors' judgment.

Q: Marketing pharmaceutical products directly to consumers is often referred to as patient or consumer "education." Is that claim a misrepresentation?

Silk: The question of whether advertising "informs" or "persuades" consumers is the subject of a long and ongoing stream of debate and research. The distinction matters since it can be shown that these two views give rise to quite different predictions about how advertising affects competition and consumers.

For example, under the "informative" , advertising tends to encourage price competition while "persuasive" advertising tends to inhibit price competition. Clearly, both kinds of advertising exist. The total U.S. expenditures on media advertising are equally split between "national" (e.g., brand) and "local" (e.g., retail) advertising. The informative applies to local advertising by retailers to inform consumers about availability and price. On the other hand, a large share of national advertising is used for brand building and is intended to be persuasive.

Weissman: Elements of both information and persuasion can be found in DTCA. That duality is evident in the results of our study. More than 70 percent of physicians endorsed the view that DTCA "informs and educates" patients while the same proportion expressed concerns about its persuasive power to "encourage patients to seek treatments they do not need." Critics of DTCA question the accuracy of its content and 82 percent of the physicians in our sample strongly or partially agreed with the view that DTCA "does not provide information on risks and benefits in a balanced manner."

It would be important to determine how often physicians feel pressured into prescribing drugs inappropriately.— Joel Weissman

Although persuasion may be desirable from a medical perspective, just under half of our respondents agreed that DTCA "increases patients' compliance with doctor recommendations, tests, or prescriptions." This is illustrated by the fact that some of the most common conditions such as high cholesterol, diabetes, and depression addressed by DTCA are often under-diagnosed or under-treated in the general population. Therefore, for these conditions, DTCA may provide educational value by informing and encouraging consumers to take advantage of the best treatments available. Other conditions, such as heartburn, can often be treated with changes in diet and lifestyle, or by less expensive drugs. Critics of DTCA claim that for conditions like heartburn, advertising may do more harm than good.

Silk: Keep in mind that the use of DTCA by pharmaceutical companies is quite selective in that it tends to be concentrated in a relatively small number of therapeutic classes. The informative and persuasive views of DTCA may differentially apply to different brands and categories at various stages of market development. Much of the controversy surrounding DTCA involves the question of whether advertising informs rather than persuades. Our present knowledge about the functions of DTCA with respect to that distinction is quite limited.

Q: Did the physicians in your sample experience an increase in reports of conditions associated with advertiser drugs?

Weissman: Yes. Medical conditions that go undiagnosed and/or untreated are concerns for health care professionals. Physicians reported that 25 percent of patient visits stimulated by DTCA resulted in a new diagnosis. Approximately 30 percent of those diagnoses were for "high priority" conditions, as defined by professional standards.

Q: How likely are physicians to prescribe a name brand that the patient requests? How successful is DTCA?

Silk: The physician prescribed the drug in 39 percent of visits with patients that involved a discussion of DTCA. Thus, most DTCA visits (61 percent) did not result in a prescription for the advertised drug. The most common reasons given were that a different drug was more appropriate or that another equally effective but less costly drug was available. Physicians in primary care and those practicing in HMOs were twice as likely as others to cite this reason. About one-fifth of the time the physician did not prescribe the drug because of the patient's choice, after the discussion occurred.

In addition to prescribing a drug, other actions were taken by physicians following DTCA discussions with patients. Such actions involved referring the patient to a specialist, suggesting a lifestyle change, and recommending an OTC (over-the-counter) drug or diagnostic test. For some of these actions, the likelihood of undertaking them was related to the physician's overall perception of DTCA.

To illustrate, physicians who viewed DTCA positively were more likely to prescribe a DTCA drug, suggest a lifestyle change, or recommend a diagnostic test. Those with negative or neutral views of DTCA were more likely to take actions other than prescribing the advertised drug or no action at all.

Q: What research needs to be done on DTCA?

Weissman: Our survey adds to the evidence that physician-patient visits involving discussions of DTCA are associated with health care actions taken that transcend merely prescribing the advertised drug, including prescribing other drugs, making lifestyle recommendations, and undertaking entirely new treatments. While such results are intriguing, future research should determine to what extent the visits and/or ensuing actions we found might have taken place in the absence of DTCA. In addition, it would be important to determine how often physicians feel pressured into prescribing drugs inappropriately, and if this affects patient health.

Silk: An important question facing policymakers is rising health care costs that some attribute, in part, to greater promotional spending. We did not ask physicians whether an available alternative drug was more or less costly than the advertised drug, primarily because physicians are not always aware of drug prices. Economic research is needed on the comparative transaction prices of substitutes for DTCA drugs and the effects of DTCA on the price sensitivity of prescribing and usage behavior. Much remains to be learned about market and competitive response to DTCA, within and across drug classes.